Radiological and Clinical Outcomes of Transforaminal vs. Posterior Lumbar Interbody Fusions: A Systematic Review.

AIM: To compare 1 and 2 level posterior lumbar interbody fusion (PLIF) to transforaminal lumbar interbody fusion (TLIF) techniques in an effort to elucidate trends in overall radiological and clinical outcome, rate of complications, operation time, length of hospital stay, reoperation rate, pseudoarthrosis or failure rate, and estimated blood loss. MATERIAL AND METHODS: Online databases including Scopus, Science Direct, Clinical key, Ovid, Embase, and PubMed/ Medline were queried over the period encompassing January 2000 to August 2021 for suitable studies. Search criteria consisted of ("TLIF" AND "PLIF") OR ("Transforaminal Lumbar interbody fusion" AND "Posterior lumbar interbody fusion") AND ("comparative" OR "comparison") OR ("fusion" OR "outcome" Or "reoperation" OR "Failure rate" OR "Failure" OR "Complication rate" OR "Complication"). RESULTS: Fourteen eligible studies were selected. Neurological deficits were considerably higher in the PLIF group (24%vs.10%). The mean operation time and estimated blood loss for PLIF and TLIF were 178.5 min and 515 ml; and 160 min and 405 ml, respectively. No significant difference was found regarding the fusion rate. The reoperation rate was greater in PLIF (2%) than TLIF (0%). No clear difference was found regarding the length of stay (LOS) and surgical site infection (SSI). CONCLUSION: The superiority of TLIF over PLIF may be evidenced by the lower rate of neurologic deficit, surgical technical aspects, less blood loss and shorter operation time. Cage migration, screw displacement, infection, and pseudoarthrosis may be influenced by a variety of factors, including the facility, the surgeon, and the instrumentation/ graft used, and do not appear to be different. Multicenter non-randomized prospective trials are recommended to determine the possible superiority of one method over the other.

Software-assisted preoperative planning of S1 Alar Iliac screws: a 3D morphometric and anatomical study.

PURPOSE: S1 alar iliac (S1AI) trajectory has gained popularity as a salvage technique for revision surgeries and failed constructs in the lumbopelvic region. This study aims to investigate the morphometry of this new trajectory based on 3D models. The possible role of gender, ethnicity and view angle (surgeon's vs. radiologist's) was investigated. METHODS: Computed tomography-driven virtual 3D models of spinopelvic region were created applying Materialize MIMICS software, and assessed for coronal and sagittal radiographic versus surgeon's view angles, and morphometry of the screw trajectory. Independent-samples t test was used to analyze the results. P value was set at < = 0.05. The Statistical Package for the Social Sciences Software (SPSS version 24.0) was used for the statistical analysis. RESULTS: A total of 164 3D models were simulated with a total 328 screws inserted satisfactorily within the S1AI trajectory. S1AI instrumentation was feasible in 96.48%. The mean radiological coronal angle was 50.619' ± 8.590' and the mean coronal angle for surgeons' perspective was 10.263' ± 5.860'. The mean radiological and surgeon's perspective sagittal angles were found to be 44.532' ± 6.424' and 31.164' ± 5.455', respectively. A statistically significant difference was found between anatomical and surgeon's perspective trajectories. Neither the pelvic laterality nor the gender influence the screw angles, length and diameter in radiological versus surgeon's view angles. CONCLUSION: Preoperative 3D modeling would be an invaluable adjunct to increase the accuracy of S1AI screw placement. Surgeon's perspective of the trajectory differs from standard CT sections and should be considered in preoperative planning.

Modified Ondra's Formula to Predict Post-Op SVA after Lumbar PSO: A Preliminary Report Verified by Simulated Post-op Images Via Surgimap Software.

AIM: This study aimed to introduce a new mathematical formula to predict sagittal vertical axis (SVA) changes after lumbar pedicle subtraction osteotomy (PSO). MATERIAL AND METHODS: This cross-sectional study included 43 patients. Lateral full spinal radiographs were exported from Picture Archiving and Communicating Systemand imported to Surgimap (NemarisInc,New York, NY, version 2.3.1.1) software for PSO simulation. Regression analysis was done on the first 16 cases to find a constant variable (K) in the proposed formula. PSOs of 15°, 20°,25°, 30°, and 35°were simulated at L3,L4, and L5 for each patient, and the simulated postoperative SVAs were compared to predict postoperative SVA. Paired T-Test, Spearman test, and analysis of variance were applied to analyze the results. The Statistical Package for the Social Sciences software (Version 24.0) was used for the statistical analysis. RESULTS: Postoperative SVA was different in terms of PSO level and degree, with a mean of 74.87±37.88, 66.12±38.33, and 56.95±38.53 at 15°; 61.76±36.68, 50.13±37.32, and 43.03±36.67 at 20°; 48.61±35.60, 39.13±35.35, and 43.18±31.56 at 25°; and 37.73±33.78, 42.38±28.76, and 44.81±16.85 at 30° for L3, L4, and L5, respectively (P 0.05). The mean difference between the predicted SVA using the formula and the SVA simulated using Surgimap software was 2.37, 2.09, and 0.47 mm atL3, L4, andL5 levels, respectively. The mathematical formula was highly predictive for postoperative simulated SVA values in all three vertebral levels (L3-L5) (P 0.05). Additionally, a strong relationship was found between the vertebral level and the amount of SVA correction (Spearman correlation: 0.7-0.9). CONCLUSION: The mathematical formula is an accurate predictor of postoperative SVA and is helpful in PSO surgical planning. However, future studies are recommended to verify its accuracy in a clinical setting.

A Novel Technique for Prevention of Subarachnoid-Pleural Fistula After Incidental Durotomy During Transthoracic Spinal Surgery.

BACKGROUND: Subarachnoid-pleural fistulas (SPFs) are rare but significant complications of transthoracic spinal surgery. Whether noted intraoperatively or in the postoperative period, SPF requires implementation of aggressive management, with consideration given to direct surgical repair. Additionally, the physical constraints of the thoracic cavity often hinder direct SPF repair. OBJECTIVE: To present a novel operative technique that can be used to easily and quickly address incidental durotomy incurred during transthoracic spinal surgery while working within the confines of the thorax. METHODS: Surgical hemostatic clips were used to affix a patch-graft of dural substitute to the parietal pleura surrounding the site of a transthoracic spinal decompression in which an incidental durotomy was incurred. The patch-graft was augmented with the application of biological glue and was successful in preventing symptomatic SPF. RESULTS: The use of surgical clips to affix a patch graft is a quick, easy, and effective means of addressing an incidental durotomy during thoracotomy and preventing SPF. The clip applier is significantly easier to maneuver within the narrow working channel of the thorax than are instruments used during direct repair. CONCLUSION: Preventing SPF can be challenging. The physical constraints of the thoracic cavity make water-tight repair difficult and time-consuming, particularly when the morphology of the dural tear prevents primary apposition of the defect. The authors present a novel technique of preventing development of SPF using hemostatic clips to simply and quickly affix suturable dural substitute to the parietal pleura overlying the site of an incidental durotomy.

Spontaneous Fusion of S2/S3 Spondyloptosis in an Adult.

BACKGROUND: Spondyloptosis is grade V on the Meyerding classification. Traumatic spondyloptosis can occur throughout the spinal column, particularly at junctional levels, and finding an ideal surgical strategy to address it remains a challenge for spinal surgeons. The sacrum is considered a united bone in adults, and sacral intersegmental spondyloptosis is extremely rare. CASE REPORT: Herein, we present an unusual case of S2/S3 spondyloptosis in a 27-year-old female patient with spontaneous solid fusion. CONCLUSIONS: This case demonstrates that similar distal sacral pathologies may be managed conservatively when there is no associated neurologic deficit, and the osteodiskoligamentous integrity of the lumbosacropelvic unit remains intact. Our report plus the very few published papers in the literature illustrate the natural history of uncomplicated traumatic spondyloptosis and support the role of in situ fusion and instrumentation as a reliable alternative to circumferential fusion in patients who cannot tolerate staged or prolonged operations.

Cervical osteochondroma with neurological symptoms: literature review and a case report.

INTRODUCTION: Osteochondromas are common benign tumors of bone and spinal involvement is uncommon. Solitary spinal osteochondromas may produce a wide variety of symptoms depending on their location and relationship to adjacent neural structures. CASE PRESENTATION: Herein, we present a case of solitary osteochondroma arising from the posterior arch of C1, causing left-sided ascending numbness and paresthesia and difficulty walking. The lesion was totally resected through a posterior approach. Histopathological examination confirmed the diagnosis of benign osteochondroma. DISCUSSION: Spinal cord compression is uncommon in spinal osteochondromas because in most cases the tumor grows out of the spinal column. To prevent neurological compromise, complete surgical removal is mandatory when an intraspinal osteochondroma with cord compression is diagnosed, which also helps to prevent recurrence. Our literature review of similar cases indicates that despite the old belief that C2 is the most commonly involved vertebra for osteochondromas, C1 is actually the most commonly involved vertebra in the cervical region.

Interspinous implants: are the new implants better than the last generation? A review.

PURPOSE OF REVIEW: Interspinous process devices (IPDs) are used in the surgical treatment of lumbar spinal stenosis. The purpose of this review is to compare the first generation with the next-generation devices in terms of complications, device failure, reoperation rates, symptom relief, and outcome. RECENT FINDINGS: Thirty-seven studies were included from 2011 to 2016. Device failure occurred at a mean of 3.7%, with a lower tendency to happen with next-generation IPDs. Reoperations occurred at a lower rate with the next-generation devices, with a mean follow up of 24 months (3.7% vs. 11.1%). The clinical outcome is not influenced by the type of IPD. The long-term functionality of these devices is questionable, with radiologic changes and recurrence of symptoms often seen by 2 years following implantation. Next-generation devices do not appear to be subject to the same "bounce back" effect of symptom re-emergence after several years.

Mapping the Internal Anatomy of the Lateral Brainstem: Anatomical Study with Application to Far Lateral Approaches to Intrinsic Brainstem Tumors.

INTRODUCTION: Intramedullary brainstem tumors present a special challenge to the neurosurgeon. Unfortunately, there is no ideal part of the brainstem to incise for approaches to such pathology. Therefore, the present study was performed to identify what incisions on the lateral brainstem would result in the least amount of damage to eloquent tracts and nuclei. Case illustrations are also discussed. MATERIALS AND METHODS: Eight human brainstems were evaluated. Based on dissections and the use of standard atlases of brainstem anatomy, the most important deeper brainstem structures were mapped to the surface of the lateral brainstem. RESULTS: With these data, we defined superior acute and inferior obtuse corridors for surgical entrance into the lateral brainstem that would minimize injury to deeper tracts and nuclei, the damage to which would result in significant morbidity. CONCLUSIONS: To our knowledge, a superficial map of the lateral brainstem for identifying deeper lying and clinically significant nuclei and tracts has not previously been available. Such data might decrease patient morbidity following biopsy or tumor removal or aspiration of brainstem hemorrhage. Additionally, this information can be coupled with the previous literature on approaches into the fourth ventricular floor for more complex, multidimensional lesions.

Intraventricular schwannoma in a child. Literature review and case illustration.

BACKGROUND: Intraventricular schwannoma remains a rare entity in the literature. Controversy exists on the possible pathogenesis of such a tumor within cerebral ventricles. Literature is sparse on tumor characteristics and differences between pediatric and adult patients. CASE REPORT: We present a case of intraventricular schwannoma in a 9-year-old patient presenting with headache, hemiparesis, and focal seizure. Brain CT scan and MRI revealed an intraventricular tumor within left atrium of lateral ventricle. The patient underwent total resection of the tumor via posterior parietal approach. Histopathological exam was in favor of schwannoma. Postoperative brain MRI and MRS showed no recurrence after 18 months. CONCLUSION: Our review of the literature indicates there are some significant differences between pediatric and adult cases in different aspects including gender predominance, intraventricular location, malignant transformation, tendency for recurrence, and surgical outcome. This needs to be taken into account in the literature.

Effect of progesterone administration on prognosis of patients with diffuse axonal injury due to severe head trauma.

OBJECTIVE: Severe traumatic brain injury (TBI) has a major role in mortality rate among the other types of trauma. The aim of this clinical study was to assess the effect of progesterone on the improvement of neurologic outcome in patients with acute severe TBI. METHODS: A total of 76 patients who had arrived within 8h of injury with a Glasgow Coma Score≤8 were enrolled in the study. In a randomized style 38 received progesterone (1mg/kg per 12h for 5 days) and 38 did not. RESULTS: There was a better recovery rate and GOS score for the patients who were given progesterone than for those in the control group in a 3-months follow-up period (50% vs. 21%); subgroup analysis showed a significant difference in the percentage of favorable outcome between the two groups with GCS of 5-8 (p=0.03). CONCLUSION: The use of progesterone may significantly improve neurologic outcome of patients suffering severe TBI up to 3 months after injury, especially those with 5≤GCS≤8, providing a potential benefit to the treatment of acute severe TBI patients. Considering this drug had no significant side effects, so progesterone could be used in patients with severe TBI as a neuro-protective drug.

Post-craniotomy blindness in the supine position: Unlikely or ignored?

Immediate visual loss following craniotomy in the supine position is a disastrous complication in neurosurgical patients. The incidence is unknown and little is known on the definite pathogenesis. Also, preventive or restorative interventions are unclear. We describe the rare case of post-craniotomy optic neuropathy and sudden visual loss after craniotomy in the supine position for an olfactory groove meningioma, discuss the possible pathophysiology and review the literature on the pathogenesis, risk factors, and outcome. Although rare, neurosurgeons, as well as neuroanesthesiologists should be aware of the possibility of this devastating complication in the high-risk group of patients.

Combined spinal cord and peripheral nerve field stimulation for persistent post-herniorrhaphy pain.

OBJECTIVES: Chronic post-hernia pain is a common complication after inguinal herniorrhaphies. Peripheral nerve field stimulation (PNFS) and spinal cord stimulation (SCS) are two new promising treatment modalities. Four patients with persistent neuropathic post-hernia pain were recruited for this prospective study. MATERIALS AND METHODS: Electrodes were inserted into the epidural space of the spinal canal and into the subcutaneous tissue in the inguinal region during a single surgical procedure. During a 14-day trial, double-blind stimulation was performed via an external stimulator: three days using the spinal electrode (SCS), three days using the inguinal electrode (PNFS), three days using both (SCS + PNFS), and five days off, with an alternating order from patient to patient. During the trial, pain intensity was assessed thrice daily by the visual analog scale. Additionally, pain intensity and quality of life (QOL) were assessed before and after surgical intervention by the Brief Pain Inventory, SF36 scale, and Pain Disability Index. RESULTS: All patients had a marked pain reduction during the trial phase, and this reduction was more prominent when both electrodes were activated simultaneously (p < 0.001). At the late follow-up, a significant pain reduction and improvement of QOL was observed in three patients. CONCLUSIONS: Both SCS and PNFS are effective in treating post-hernia pain, but the magnitude of pain reduction was more prominent with concomitant stimulation. Combined PNFS and SCS should be considered for patients with a less than optimal response to either SCS or PNFS. More studies are necessary to address the cost-effect issues of this new approach to treatment.

Basioccipital bone osteochondroma growing into the foramen magnum.

BACKGROUND: Osteochondroma is a common bone tumor and rarely affects the central nervous system. Although intraspinal osteochondromas are known to cause neurological deficits, intracranial osteochondromas with neurological compromise are very rare. CASE DESCRIPTION: The authors report an exceptional case of a quadriparetic 73-year-old patient with a basioccipital bone osteochondroma growing into the foramen magnum. The embryology, differential diagnoses, and optimal management strategies are discussed. CONCLUSION: Although extremely rare, osteochondromas should be included in the differential diagnoses of tumors within the foramen magnum. For the tumors originating from the basioccipital bone, a simple medial suboccipital approach might suffice, while for ventral tumors, a far lateral transcondylar approach is necessary to avoid any neurovascular complications. Despite potentially catastrophic presenting symptoms, these tumors are pathologically benign and complete excision often results in long-term cure. To the best of our knowledge, this is the first report of an osteochondroma arising from the basiocciput.

Antibiotic susceptibility patterns of pseudomonas corneal ulcers in contact lens wearers.

PURPOSE: To evaluate the resistance or susceptibility of Pseudomonas aeruginosa, the most common pathogen in contact lens keratitis and corneal ulcer, to different antibiotic regimens. MATERIALS AND METHODS: This cross-sectional study included all patients with recently diagnosed contact lens corneal ulcer whose culture results were positive for P. aeruginosa, from March 2009 to March 2010. The empirical antibiotic therapy was changed to appropriate antibiotics according to the culture results, provided that satisfactory clinical improvement was not achieved with the initial antibiotic regimen. The overall sensitivity or resistance of P. aeruginosa to the most commonly used antibiotics was assessed based on the results of the antibiograms. RESULTS: Fifty-two patients (43 females and 9 males) were included. Forty-five patients (86%) were wearing cosmetic contact lenses, while 7 patients (14%) were using therapeutic contact lenses. Thirty-nine patients (75%) were hospitalized and13 patients (25%) were followed up through an outpatient clinic. Thirty patients (58%) had central ulcers, whereas 22 patients (42%) had peripheral ulcers. Twelve patients (23%) had hypopyon in their first exam. The mean time to diagnose the ulcer after the last time wearing was 2 days (range: 12 hours to 5 days). AMT was required for 10 patients (19%). Based on the antibiograms, PA was shown to be sensitive in 100% of cases to ceftazidime and ciprofloxacin. Amikacin, imipenem, and gentamicin were the second most effective antibiotics. CONCLUSION: P. aeruginosa was highly sensitive to ceftazidime, ciprofloxacin, and amikacin. All cases were resistant to cefazolin. Resistance to multiple antibiotics might be a significant concern in patients with corneal ulcers. In referral centers dealing with corneal ulcers, the initial antibiotic regimens should be changed from time to time to prevent this phenomenon.

Harvey Cushing's experience with treating childhood hydrocephalus: in his own words.

PURPOSE: As the founder of modern neurosurgery, Harvey Cushing is known for his innovations and treatment for many neurosurgical disorders. However, few are aware that Cushing treated childhood hydrocephalus. Examples of these treatments include the placement of ventriculo-subgaleal shunts, ventriculo-jugular shunts, ventriculo-superior sagittal sinus shunts, and at least 12 lumbar cistern-to-retroperitoneal shunts that, as he put it, had "a considerable measure of success." The authors wish to provide insight into Cushing's treatment of childhood hydrocephalus. METHODS: The authors review Cushing's writings on this topic. RESULTS: The authors provide a window into this pioneer's early thinking on the physiology and production of cerebrospinal fluid. CONCLUSIONS: Although decades went by before reliable treatments for hydrocephalus were established, Cushing pioneered both the thought processes and surgical options for this disease.

Hubert von Luschka (1820-1875): his life, discoveries, and contributions to our understanding of the nervous system.

One of the most prolific anatomical writers of the 19th century, Hubert von Luschka made significant contributions to our knowledge of neuroanatomy. His publications and textbooks were standards for their day. However, very little is written of his life in either the English or the German literature. His name lives on eponymously in more than 20 anatomical structures, including those most relevant to the neurosurgeon, the foramina of Luschka and uncovertebral joints. In this article, the authors discuss the life and contributions of this prominent German surgeon and anatomist.

Neurological manifestations, imaging characteristics, and surgical outcome of intraspinal osteochondroma.

OBJECT: Spinal osteochondromas (OCs) are rare and can originate as solitary lesions or in the context of hereditary multiple exostoses. Concurrent spinal cord compression is a very rare entity. The purpose of this study was to evaluate the authors' 10-year experience with the imaging characteristics and surgical outcome in patients with symptomatic spinal OC. METHODS: Between 1997 and 2007, 8 consecutive cases of symptomatic intraspinal OC with documented spinal cord compression were treated surgically. These patients were analyzed with regard to presentation, imaging, and outcome. The relevant English literature was reviewed using MEDLINE and Google search engines. RESULTS: Three patients had cervical, 2 had thoracic, and 3 had lumbar lesions. Classic MR imaging characteristics were rarely found. Multiple hereditary exostoses were equally responsible for cervical, thoracic, and lumbar lesions (33%). The origin of the lesion was from the pedicle (25%), lamina (25%), vertebral body (25%), and superior or inferior facets (25%). A posterior approach to the spine was used in 6 patients, and a combined anterior and posterior approach with fusion was performed for 2 thoracic lesions. Surgical outcome was satisfactory in 75% of patients. The prognosis was poor in the patients with thoracic lesions. CONCLUSIONS: In the authors' experience, early detection and surgical removal in cases of symptomatic spinal OC is a key element for the best outcome. Posterior approaches are generally sufficient. The chronicity of symptoms may limit functional recovery postoperatively, especially with cervical and thoracic lesions.